What is the appropriate treatment for a patient with proctitis?

Treatment of Proctitis

For patients with acute proctitis of recent onset who have practiced receptive anal intercourse, the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Anoscopy examination - To visualize inflammation and collect samples
2. Laboratory testing for common sexually transmitted pathogens:
   • HSV (PCR or culture)
   • N. gonorrhoeae (NAAT or culture)
   • C. trachomatis (NAAT)
   • T. pallidum (serologic testing)

If anorectal exudate is present or polymorphonuclear leukocytes are detected on a Gram-stained smear, empiric treatment should be started while awaiting test results 1.

Treatment Algorithm Based on Etiology

1. Sexually Transmitted Proctitis

• Standard treatment: Ceftriaxone 250 mg IM (single dose) + Doxycycline 100 mg BID for 7 days 1
• For patients with bloody discharge, perianal ulcers, or mucosal ulcers with positive rectal chlamydia NAAT or HIV infection: Consider extending doxycycline to 3 weeks total for presumptive LGV treatment 1
• If painful perianal ulcers present: Add treatment for genital herpes 1

2. Inflammatory (Ulcerative) Proctitis

• First-line: Mesalamine (5-ASA) 1g suppository once daily 2
• Alternative options:
  • Reduce frequency to every 2nd or 3rd day to improve adherence
  • Switch to oral 5-ASA
  • Combine topical mesalamine with oral mesalamine or topical steroids for better efficacy 2

Special Considerations

HIV Co-infection

• Herpes proctitis can be especially severe in patients with HIV 1
• All patients with acute proctitis should be tested for HIV 1, 2

Partner Management

• Sexual partners within 60 days before symptom onset should be evaluated, tested, and presumptively treated for the respective pathogen 1
• Partners should abstain from sexual intercourse until both they and the patient with proctitis are adequately treated 1

Follow-up

• Based on specific etiology and severity of clinical symptoms
• For proctitis associated with gonorrhea or chlamydia, retesting should be performed 3 months after treatment 1, 2
• Reinfection may be difficult to distinguish from treatment failure 1

Common Pitfalls to Avoid

1. Failing to distinguish between infectious and inflammatory causes - Both can present with similar symptoms but require different treatments 3, 4

2. Not considering proximal constipation - This can affect drug delivery in distal colitis and should be addressed with laxatives if present 1

3. Overlooking co-infections - Multiple pathogens may be present simultaneously, particularly in sexually transmitted cases 4

4. Missing refractory disease - For patients who fail conventional therapy, consider:

   • IV steroid therapy
   • Alternative topical therapies
   • Surgical options if disease persists 1

5. Not testing for Mycoplasma genitalium - This should be considered in patients with symptomatic proctitis after exclusion of other common causes 5, 4

By following this structured approach to diagnosis and treatment, clinicians can effectively manage proctitis and improve patient outcomes while reducing the risk of complications and transmission.